• Reaction Form

    *******************************************ATTENTION********************************************** THIS FORM IS FOR HEALTH REACTIONS ONLY. TO RECEIVE HELP WITH OTHER CONCERNS PLEASE EMAIL customerservice@ultraceuticals.com.au
  • When did the reaction occur?*
     - -
  • State/Country where the reaction occurred?*

  • Where did you purchase the product/s?*

  • Product/Treatment Identification

  • Image field 36

  • Reaction

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  • Did the client need to see a Doctor or other medical professional (nurse / pharmacist etc)?*
  • Did the reaction require a prescribed treatment by a medical practitioner?*
  • Has the client recovered from the reaction?*
  • How long did it take them to recover?*
  • Has the client had any history of skin sensitivity/allergic reaction?*

  • Client identification

    the person who experienced the reaction
  • Sex*
  • Do we have the person's consent to disclose details of affected person to relevant regulatory & government authorities in your country eg ACCC, TGA, etc?*
  •  -
  • Should be Empty: